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General Policy
Estates, Facilities and Capital Services
Estates Services Manager
Head of Estates & Facilities
Director of Estates, Facilities, & Capital Services
01 August 2006
26 October 2020
26 October 2023

General Note

NHS Fife acknowledges and agrees with the importance of regular and timely review of policy statements and aims to review policies within the timescales set out.
New policies/procedures will be subject to a review date of no more than 1 year from the date of first issue.

Reviewed policies will have a review date set that is relevant to the content (advised by the author) but will be no longer than 3 years.

If a policy/procedure is past its review date then the content will remain extant until such time as the policy review is complete and the new version published.


1.1 This policy is supported by the NHS Fife Contractors Health & Safety Requirements Code of Practice for Contractors to ensure they adopt safe working practices and environmental measures in compliance with relevant statutory requirements when employed on NHS Fife contracts.

1.2 The policy will apply with respect to NHS Fife contracts and projects to ensure that an effective process is followed to ensure that only competent and suitable contractors are considered and selected for operation within NHS Fife.


2.1 This policy applies to contracts carried out on all NHS Fife equipment and properties including hospitals, health centres and clinics, administrative buildings, laundry, laboratories, residential and other miscellaneous properties throughout the whole of Fife.


3.1 NHS Fife has a legal responsibility to ensure the health, safety and welfare of all parties associated with works including contractors, employees, NHS staff, patients, visitors and members of the public who may be affected by activities on sites owned and managed by NHS Fife.

3.2 An organisational structure for any project or works must be established in accordance with current recommendations such as the Scottish Capital Investment Manual or Construction, Design and Management Regulations, so that roles and responsibilities are clearly set out and complied with.

3.3 This policy covers all maintenance and construction work carried out by principal contractors and sub-contractors employed on NHS Fife contracts. Non-compliance with the code of practice (or the Policy) and other relevant statutory guidelines may result in immediate termination of the contract and removal of the contractor involved from NHS Fife’s approved list.

3.4 The Head of Estates shall ensure that this Policy and appropriate records are monitored on a regular basis and reviewed annually.


4.1 The Code of Practice for NHS Fife is comprehensively described in ‘NHS in Scotland Procode – Vetting and Control of Contractors (section 1.11) Guidance Notes and Sample Documentation”

4.2 The Guidance Notes cover the following:-

• Site Safety Agenda;
• Selection of Contractors;
• Contractor Guidance;
• Contract Documents;
• Tender Reports;
• Contractor Formal Briefing;
• Health and Safety File;
• CDM Regulations;
• Review of Contractor Site Performance.

4.3 NHS Fife and its employees and all principal contractors and sub-contractors employed on construction contracts are legally bound by various statutory instruments, including (not exhaustive):-

• The Health and Safety at Work Act 1974;
• The Management of Health and Safety at Work Regulations 1992;
• The Construction (Design and Management) Regulations 2015;
• The Workplace (Health, Safety and Welfare) Regulations 1992;
• The Provision and Use of Work Equipment Regulations 1998;
• The Electricity at Work Regulations 1989;
• COSHH Regulations 2002;
• Control of Asbestos Regulation 2012.

4.4 NHS Fife Estates Department maintains, reviews and updates a Contractor’s Health and Safety Requirements Code of Practice which applies to all maintenance work, construction projects, employees, principal contractors and sub-contractors. All employees and contractors must be issued with a copy of the Code of Practice to ensure they are familiar with its requirements, obligations and restrictions which are applicable and relevant.

4.5 NHS Fife collates a database of approved contractors deemed suitable for work on contracts. Inclusion on the database will be conditional on potential contractors completing a contractors’ questionnaire pro-forma.

The main criteria for consideration prior to placing a contractor on the approved database or tender list are: contractor competence including previous experience of similar work in NHS/healthcare environment, health and safety performance, inclusion on an SSIP (Safety Schemes in Procurement) accredited database such as Construction Line or Safe Contractor, availability of resources to successfully complete a contract within the required timescale and company turnover/monetary value relative to the estimated value of the proposed contract, with sufficient insurance cover.

4.6 The Project Director, based on advice from the Project Manager/Design Team, will confirm whether, under certain circumstances and in conjunction with the application of this policy, a pre-qualification process may also be required prior to compiling a suitable tender list. The pre-qualification process will be carried out in accordance with Procode.

4.7 NHS Fife Estates Department retains an approved list of contractors and consultants which is monitored and updated at least annually.


5.1 The person engaging any contractor is responsible for ensuring that risks associated with the works are adequately controlled. The measures needed to achieve this will depend on the nature and complexity of the work being done. This may range from a setting to work procedure for the simplest project through to pre qualification systems, vetting and risk control measures for complex work.

On larger projects, the Project Director is responsible for ensuring the following:-

• Robust risk control measures are in place;
• A Risk Register is set up;
• Regular review of the Risk Register.


• NHS Fife Contractors’ Health and Safety Requirements Code of Practice;


• Procode (Version 2, 2002) Property and Environment Fund;
• NHS HDL (2002) 87 – Revised Interim Capital Guidance (Scottish Executive Health Department);
• Scottish Capital Investment Manual;
• The Health and Safety at Work Act 1974;
• The Workplace (Health, Safety and Welfare) Regulations 1992;
• The Provision and Use of Work Equipment Regulations 1998;
• The Electricity Work Regulations 1989;
• The Construction (Design and Management) Regulations 2015.